To make an appointment and send referrals to:
Make an appointment and send referrals to: 
Fax:      (02) 4634 4045 
Phone: (02) 4634 4028
Email: Renuka.Singh3@health.nsw.gov.au
			                                 
Wollondilly Diabetes Program Referral Form
This program is for people living with Type 2 Diabetes residing in the Wollondilly LGA
Dr Chau Tran - Endocrinologist 
DEAR DR <<Addressee:Name>>
Date: <<Miscellaneous:Date>>

I would like to refer the patient with Type 2 Diabetes for:
           
     q Endocrinologist Consultation 
     q Diabetes Educator Individual Education 
     q Diabetes Educator Group Education    
           
PATIENT NAME:	<<Patient Demographics:Full Name>>	
ADDRESS:	<<Patient Demographics:Address>>, <<Patient Demographics:City>>, <<Patient Demographics:State>>, <<Patient Demographics:Postcode>>	
DATE OF BIRTH:	<<Patient Demographics:DOB>>	   	
PHONE NUMBER:	Home: <<Patient Demographics:Phone (Home)>>      Mobile: <<Patient Demographics:Phone (Mobile)>>	
MEDICARE 	<<Patient Demographics:Medicare Number>>	

AGE:  <<Patient Demographics:Age>>   	 DURATION OF TYPE 2 DIABETES:   <<Duration of Type 2 diabetes years>> year/s 	

The most recent HbA1c was <<Clinical Details:Measurements (Selected)>> 		

REASON FOR REFERRAL:  <<Reason for referral >>

Thank you for your advice and help in the continuing management of this patient.

Yours sincerely,

Referring Doctor: <<Doctor:Name>>    Provider Number: <<Doctor:Provider Number>>

Address: <<Doctor:Address>>, <<Doctor:City>> <<Doctor:State>> <<Doctor:Postcode>>           Telephone: <<Doctor:Phone>>

Signature: …………………………………………                                               Date: <<Miscellaneous:Date>>

 

PLEASE ATTACH

Clinical History:

<<Clinical Details:History List>>

Current Medication List:

<<Clinical Details:Medication List>>

Investigations:

Investigation summary
<<Summary:Investigation Results (Selected)>>

Clinical details: 
<<Clinical Details:Measurements (Selected)>>